Mr. P. J. Du Plessis, the
Magistrate presiding over the Judicial Inquest into the deaths caused by the
fatal aircraft accident near Rand Airport on 6 December 1999, in which 10 lives
were lost, released his findings and recommendations yesterday. The Judicial
Inquest was conducted over sixteen days during April 2002.
The CAA
welcomed and cooperated fully with the inquest proceedings and hoped that this
process would assist in closing this tragic event, particularly for the
families of the victims of the crash.
The
crashed aircraft operated by Flightline Charters had
taken off from Rand Airport on a commercial charter flight to Orangemund in Namibia, when shortly after taking off, the
pilot reported an emergency to the control tower and requested clearance to
return to the airport to land. The aircraft crashed about two minutes after
take off and everybody on board lost their lives.
The
investigation into the accident, conducted by the CAA, revealed that the
probable cause of the accident was the failure of a critical exhaust pipe
segment, which in turn caused the right-hand engine to lose power/fail. It is
was also found that the aircraft exceeded it's
designed load limit. This overloaded condition of the aircraft was thus a
highly significant contributory factor to the accident. The company’s lack of flight operations management experience,
professional flight standards supervision and an operational safety management
program were regarded as significant contributing factors. The anomalies noted in regulatory oversight
of the operator (airworthiness and flight operations surveillance by the former
Chief Directorate:CAA in the
Department of Transport and CAA are regarded as possible contributing factors.
According
to the Commissioner for Civil Aviation, Mr. Trevor Abrahams "this was a
landmark accident investigation for the Civil Aviation Authority as it
represents a whole new approach to investigating accidents through a detailed
investigation not only of the immediate circumstances and conditions
surrounding the accident, but also a close look at the chain of actions and
inactions by all connected parties that could be identified as possibly
contributing to the tragic event.
A total of 17 safety recommendations arose out
of the investigation. Fifteen of these were directed at the Civil Aviation
Authority for implementation. The other two were each directed at the pilot
community and at commercial charter operators.
In
Inquest findings highlighted the following aspects surrounding the accident.
The
aircraft sustained a power loss in the right hand engine shortly after take off
and that the pilot flew the aircraft in accordance with the pilot’s operating
handbook. The aircraft was certified to fly on one engine but that the
overweight condition resulted in the subsequent crash.
The
magistrate also found that the accident investigation conducted by the CAA was
extensive and that the overweight of the aircraft was substantially under
reported in the accident report and that the actual weight of the aircraft was
substantially more than the certified maximum take off weight limit of the
aircraft.
The
magistrate also found that the operator’s practices in loading the aircraft was
at variance with the approved operators manual of Flight Line Charter Services
in that the baggage was not weighed nor was the required weight and balance
calculated for the accident flight. The magistrate emphasized that once the CAA
approved an Operations Manual, the operators had a responsibility to ensure
compliance with that approved Operations Manual.
The
operator was found to have deviated significantly from the CAA approved
Operators Manual in terms of the critical issue of weight and balance of their
aircraft. Specifically, the accident flight was loaded to capacity and the
General Manager should have ensured proper weighing of the cargo and passengers
on the 6th of December 1999.
The
magistrate also found that the CEO of Flightline
Charter Services C.C. had erroneously amended the Pilots Operating Handbook,
thereby giving the pilot an incorrect basis for calculating the maximum take
off mass of the aircraft.
The
magistrate’s recommendations included:
1. That the CAA consider disciplinary steps
against officers who accepted the patently incorrect information submitted on
the test flight report submitted to the CAA. The magistrate also ruled that the
remoteness of this action ruled out any prosecution involving the CAA.
2. That the
maintenance organization (AMO), PLACO’s failure to notify the CAA when the
Mandatory Periodic Inspections were late or over flown, was a serious indictment
of the AMO. The magistrate also found
PLACO’s conduct as the seller and registration AMO as warranting severe
criticism but that the remoteness to the actual accident ruled out prosecution.
3. That the
manner of loading of the accident flight resulted in a clear case of negligence
on the part of the operator and Mr. Declan McEneany,
in his personal capacity, in respect of each passenger.
4. That Miles
van der Molen, in his personal capacity and as CEO of
Flightline Charter Services C.C. was negligent in
relation to the death of the 9 passengers and the pilot for having erroneously
altering the pilot’s Operating Handbook.
The
CAA will study the findings and recommendations of this inquest and identify
which steps we need to take to enhance aviation safety in South Africa.
Notwithstanding
the tragic events on the 6th of December 1999, air transport remains
the safest mode of travel.
The
CAA has taken a number of steps in the wake of this accident, including the
implementation of the accident report’s safety recommendations, to ensure
continuing improvement in the level of safety in our aviation industry.
In
some cases, the CAA does encounter operators who refuse to comply with the
minimum safety requirements and ultimately have to take action to deprive them
of their licence to operate, as was done with Flightline
Charters in 2000. The CAA will continue to work with industry to enhance our
aviation safety standards but will also take decisive action to close operators
who refuse to comply with aviation safety regulations.
For Further Information, contact
Trevor Davids
Senior
Manager: Communications
SA Civil
Aviation Authority
012 426 0117
(Direct)
012 346 5979
(Fax)
083 635 0068
davidst@caa.co.za
www.caa.co.za